The waiting room

War and underfunding have decimated Iraq’s public health system, once the best in the Arab world.

After a few days of driving round Baghdad in toxic traffic, I’m feeling a little ill.

I decide a visit to Sister Marie who runs the St Raphael Hospital might be in order. It’s been 13 years since I last saw her.

Things have changed, to say the least. The hospital – across from a church in the predominantly Shi’a neighbourhood of Karradah – has had the entire street in between blocked off. Security checks are now necessary before you can even get inside. The obligatory sweep of the car with the ‘bomb detector’ (possibly a dodgy one sold to the Iraqi Ministry of Defence by a British company, currently under investigation) is now beginning to feel normal, as is the constant sight of armed men. One doesn’t usually associate kalashnikovs with hospital entrances, but these are strange times. According to the Iraqi Medical Association, 2,000 doctors have been killed since 2003 and another 12,000 have fled.

I am ushered into the office of Dr Boutros, one of Baghdad’s few remaining oncologists. He’s cagey and won’t talk on camera. I don’t blame him, especially after he tells me about some of the threats he’d received from militias in the past. But he’s also concerned about the Government response, as he still runs a clinic at a public hospital nearby. Unlike Saddam-era Iraq, when the sick and dying were often exploited for televisual anti-embargo purposes, today public hospitals are difficult for media to access.

Even after the invasion, when I was last here, I had to sneak my way into the old Saddam Children’s Hospital, to speak with one of the chief surgeons there. He painted a grim picture indeed of the state of paediatric health, saying it was actually worse than it had been under sanctions.

They had no steady supply of electricity, all the same shortages of penicillin, morphine and basics as before, as well as an unstable security situation and no operating budget from the Ministry of Health. ‘There’s no real Government,’ he’d told me. ‘It’s as if we’ve been set adrift now, all by ourselves.’

Children under five were still dying of waterborne diseases, since sanitation and water treatment facilities, in disrepair after years of war and sanctions, now had to contend with thousands of displaced people. And paediatric cancers, he told me, had increased dramatically. He was sure it was related to depleted uranium and other toxins in bombs, but as the equipment necessary to detect radiation levels had also been banned under the embargo, he had no written documentation to prove his theory.

As I spoke to Dr Boutros now, he was careful to avoid saying anything overtly critical of the Ministry of Health. But he conceded that there were severe shortages of radiation equipment for chemotherapy and that many patients (those who could afford it) had to seek care outside of Iraq.

I got the blunt truth from my friend Haydar: ‘A cancer diagnosis is a death sentence in Iraq. You only have a few months, tops.’ His analysis of the old regime/new regime situation was even blunter. ‘Same shit, different taste,’ he said with a grin.

Later, predictably, Dr Boutros cancels the appointment he’d made for me to go to his clinic at the public hospital. When I meet with Sister Marie, she still looks hale and hearty, but lacks a certain bravura of old. This nun, who had negotiated with black marketeers for penicillin, who had said of the then embargo enforcers – and by implication certain elements of the Saddam regime – ‘Those who are responsible for this, how do they sleep at night?’, is now very careful not to speak of politics. She remains tight-lipped about the Ministry of Health as well as the situation for Christians.

But as we say goodbye, I ask if there is any way that medical charities in the West might be able to send some of the equipment Dr Boutros said the hospital so needed.

‘Yes,’ she practically whispers, ‘just don’t send it through the Ministry of Health.’

It’s hard to believe that in the 1980s Iraq had the best healthcare system in the Arab world. Or that half the doctors were women.

Later I track down a doctor who is more willing to talk. Dr Azam is a consultant surgeon at a public hospital, but also runs a private clinic near St Raphael. When I arrive for our 6pm appointment, his waiting room is full, mainly with women and children.

They seem rather surprised to see a Western journalist with a video camera, but once I start chatting, the mood is friendly and generous. A middle-aged lady tells me that her mother, a tattooed hajiya in a black abaya, is here because of a cyst in her stomach. A previous operation at another private clinic at a cost of almost $5,000 had failed to remove it.

When I ask if that price is not prohibitive, the daughter shrugs and says, ‘We can afford it.’ But later she explains: ‘All of our friends and relatives chipped in and we managed.’

‘But what about a public hospital?’ I inquire. The daughter looks at me blankly. The last time she went to a public hospital was over 20 years ago.

A 35-year-old woman named Alia has come from a northern suburb of Baghdad, known for crackdowns under Saddam, its militant Shi’a militias, and ongoing violence that reached its climax during the sectarian troubles of 2006. At that time she was imprisoned in her home by militia violence and several family members were killed at sectarian ‘checkpoints’. She says that sectarianism is not an Iraqi problem but one brought on by ‘outside forces’.

She is here with her baby daughter, who has a mysterious cyst on her right cheek. To get here took her three hours on public transit and the return journey will be in the dark of night. ‘Aren’t you worried for your safety?’ I ask.

‘Khelas. What can we do? There is no clinic where I live. God will protect us.’

Alia was once a student at Baghdad University and remembers those days fondly. Now she is married to an unemployed supermarket worker and worries about the future for her three children. There are no decent schools in her area. Things are better than under sanctions, she says, but the cost of living has gone up and it’s hard to make ends meet. And running a household is difficult with only four hours a day of electricity and dodgy water.

After waiting for an hour, I am ushered into Dr Azam’s consulting room where he receives me warmly. Azam is a Shi’a and has only recently returned to Baghdad. He was targeted by militias and forced to flee to Jordan in 2006. At Medical City, the public hospital where he worked, ‘every day there was a different target. A Shi’a militia would kill a Sunni doctor and the next day a Sunni militia would kill a Shi’a doctor. It was horrible.’

Things were better then in terms of supplies – not like the mid to late 1990s during the embargo, when Azam recalls colleagues having to reuse unsterilized catheters – but too dangerous for proper functioning. ‘Militias would routinely kill patients in their beds,’ he relates.

We are 20 years behind now, but we hope things will improve as more doctors return. We need stability in this country, we need peace, before life can improve

Lured back by a slightly improved security situation and a larger salary (he tells me he now earns $25,000 a month from his private clinic alone) Azam reopened his clinic in January 2007. But the situation is far from ideal. Surgeries are often postponed because of bombs: ‘There are very long waiting lists, especially at the public hospitals. You might wait six months for your turn, but if there are wounded coming in that day after a bombing then, khelas, you have to wait another six months.’ He admits that the standards at public hospitals are so low that ‘only the desperate go there’.

Some issues affect both private and public healthcare. ‘It’s very hard to get mammograms,’ he explains. ‘We don’t have any early detection machinery and very limited ultrasounds.’ Not surprisingly, there’s also a lack of specialists left in the country.

A man interrupts our interview. I recognize him as the fellow from the waiting room who had let loose with an angry lecture on how the Americans had divided his country, which did not abate when I agreed with him, nor when I pointed out my Canadian nationality. Now he is asking about the expensive lab work the doctor has prescribed for his wife, who has an abdominal cyst. ‘Are all these tests really necessary?’ he asks.

‘Some of my colleagues are returning now,’ the doctor continues after telling the man that the tests are all required, ‘from Dubai, Syria, Libya.’ But the doctor stresses the need for outside help. Years of sanctions and post-invasion chaos mean that Iraqi doctors are often lacking medical knowledge and practical experience. ‘We are 20 years behind now,’ he says. ‘But we hope things will improve as more doctors return.’ He admits that if the security situation worsens, he would consider leaving again. ‘We need stability in this country, we need peace, before life can improve.’

And the sectarianism that almost cost him his life, says Azam – whose mother and wife are both Sunni – will fade as it did in Ireland, with the advent of economic prosperity. ‘If people have decent jobs, there will be less violence,’ he says, perhaps trying to reassure himself.

‘I am a Baghdadi and this city has always been cosmopolitan, always been a centre of learning. Things will get better.’

The doctor actually thanks me for coming, saying: ‘We need help from the outside, we can’t recover on our own.’

But when I return to the waiting room, I am met by a hostile crowd of women shouting at me, including the formerly shy Alia. My interview with the doctor has delayed her scary bus ride home in the dark by 20 minutes and she is not happy.

There is much to be angry about in Iraq. And Iraqis have been waiting for a very long time. How much longer can they hold out, I wonder, as I grab my camera and drive off into the night.

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